Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER

ICR 201908-0720-003

OMB: 0720-0020

Federal Form Document

Forms and Documents
IC Document Collections
ICR Details
0720-0020 201908-0720-003
Active 201604-0720-001
DOD/DODOASHA
Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER
Revision of a currently approved collection   No
Regular
Approved without change 10/16/2019
Retrieve Notice of Action (NOA) 08/29/2019
  Inventory as of this Action Requested Previously Approved
10/31/2022 36 Months From Approved 10/31/2019
335 0 300
112 0 100
2,087 0 1,710

The information collection requirement is necessary to ensure that applicants for TRICARE-Provider Status meet the conditions for authorization as a TRICARE Corporate Services Provider. The collected nformation will be used by TRICARE contractors to process claims and verify authorization status.

None
None

Not associated with rulemaking

  84 FR 29852 06/25/2019
84 FR 45474 08/29/2019
No

1
IC Title Form No. Form Name
Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER DD Form 3030 Corporate Services Provider Application for TRICARE Provider Status

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 335 300 0 35 0 0
Annual Time Burden (Hours) 112 100 0 12 0 0
Annual Cost Burden (Dollars) 2,087 1,710 0 377 0 0
Yes
Miscellaneous Actions
No
The burden has increased since the previous approval due to an increase in hourly wages and the total number of responses received.

$10,519
No
    No
    No
No
No
No
Uncollected
Kira Starks 571 372-4529 danikquia.k.starks.ctr@mail.mil

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/29/2019


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